CURRENT SOCIAL AND

EMOTIONAL CONCERNS
Learning Objectives

1. Describes the rights of the client in a psychiatric setting.

2. Discuss the legal and ethical issues related to seclution and
restraint.
3. Discuss the meaning of Standard of Care.
4. Describe the most common types of torts in the mental health
setting.
5. Describe the components of malpractice.
6. Identify pertinent ethical issues in the practice of Psychiatric
Nursing.
Legal considerations

•this topic will discuss the legal

considerations related to mental
health treatment and ethical
issues that commonly arise in
mental health settings.
 Rights of Clients and related issues
• Client receiving mental health care retain all civil rights afforded to all
people except to leave the hospital in case of involuntary commitment.
• RESTRICTIONS. Must be made for a verifiable, DOCUMENTED REASON. And
these decisions can be made by court or decision making person. Examples:
 a suicidal client may not be permitted to keep the belt, shoelaces, or
scissors because he or she may use these items for self-harm.
A client who becomes aggressive after having a particular visitor may have
that person restricted form visiting for a period of time.
A client making threatening phone calls to others outside the hospital may
be permitted only supervised phone calls until his or her conditions
improves.
 Highlights of patients bill of rights

To be informed about benefits, qualifications of all providers,

available treatment options, and appeals and grievance
procedures
Least restrictive environment to meet needs
Confidentiality
Choice of providers
Treatment determined by professionals, not third-party payers
Parity
Nondiscrimination
 … cont…Highlights of patients bill of rights

All benefits within scope of benefit plan

Treatment that affords greatest protection and
benefit
Fair and valid treatment review processes
Treating professionals and payers held
accountable for any caused by gross incompetence,
negligence , or clinically unjustified decisions.
 Involuntary Hospitalization

• Clients hospitalized against their will under these

conditions are committed to a facility for psychiatric
care until they no longer pose a danger to themselves or
to anyone else.
• A person can be detained in a psychiatric facility for 48
to 72 hours on an emergency basis until a hearing can be
conducted to determine whether or not he or she should
be committed to a facility for treatment for a
specialized period.
 Release from the Hospital

• In clients admitted to the hospital voluntarily have the

right to leave, provided they do not represent a danger
to themselves or others. They can even sign for AMA.
• If a voluntary client who is dangerous to him or herself
or to others signs a request for discharge, the
psychiatrist may file for civil commitment to detain the
client against his or her will until a hearing can take
place to decide the matter.
 LEAST RESTRICTIVE ENVIRONMENT
• CLIENTS HAS THE RIGHT TO TREATMENT in the least restrictive
environment appropriate to meet their needs.
• DEINSTITUTIONALIZATION- a deliberate shift from institutional
care in state hospitals to community faculties, began.
• It means that client does not have to hospitalized if he or she
can treated in an outpatient setting or in a group home. It also
means that the client must be free of restraint or seclusion
unless it is necessary.
 DUTY TO WARN

• One exception to the client’s right to confidentiality is the duty to warn.

• WHEN MAKING DECISION ABOUT WARNING A THIRD PARTY, THE CLINICIAN MUST
BASE HIS OR HER DECISION ON THE FOLLOWING:
Is the client dangerous to others?
Is the danger the result of serious mental illness?
Is the danger serious?
Are the means to carry out the threat available?
Is the danger targeted at identifiable victims?
Is the victim accessible?
 TORTS

• A tort is a wrongful act that results in injury loss, or damage.

Torts may be either unintentional or intentional.

• UNINTENTIONAL TORTS: negligence and malpractice.

NEGLIGENCE- is an unintentional tort that involves causing harm
by failing to do what a reasonable and prudent person would do
similar circumstances.
 …cont…TORTS:MALPRACTICE
• UNINTENTIONAL TORTS: negligence and malpractice.
MALPRACTICE: is a type of negligence that refers specifically to
professionals such as nurses and physicians.
• For a malpractice suit to be successful, that is, for the nurse,
physician or hospital or agency to be liable, the client or family
needs to prove 4 elements:
1. DUTY: a legally recognized relationship (i.e., physician to
client, nurse to client) existed. The nurse had a duty to the
client, meaning that the nurse was acting in the capacity of the
nurse.
 …cont…TORTS:MALPRACTICE

2. BREACH OF DUTY: the nurse (or physician) failed to conform to

standards or care, thereby breaching or failing the existing duty. The nurse
did not act as a reasonable prudent nurse would have acted in similar
circumstances.

3. INJURY OR DAMAGE: the client suffered some type of loss, damage, or

injury.

4. CAUSATION: the breach of duty was the direct cause of loss, damage,
or injury. In other words, the loss, damage or injury would not have
occurred if the nurse had acted in a reasonable, prudent manner.
 TORTS: INTENTIONAL
• Psychiatric nurses may also be liable for intentional torts or
voluntary acts that result in harm to client. Examples are
ASSAULT, BATTERY, AND FALSE IMPRISONMENT.
ASSAULT: involves any action that that causes a person to fear
being touched in a way that is offensive, insulting, or physically
injurious without consent or authority.
BATTERY: involves harmful or unwarranted contact with a client;
actual harm or injury may or may not have occurred.
FALSE IMPRISONMENT: the unjustifiable detention of a client,
such as the inappropriate use of restraint or seclusion.
 …cont…TORTS: INTENTIONAL

• PROVIDING LIABILITY FOR AN INTENTIONAL TORT

INVOLVES THREE ELEBENTS (Elsevier, 2019)
1. The act was willful and voluntary on the part of the
defendant (nurse)
2. The nurse intended to bring about consequences or
injury to the person (client)
3. The act was a substantial factor in causing injury or
consequences.
 STEPS TO AVOID LIABILITY

Practice within the scope of state laws and nurse practice act.
Collaborate with colleagues to determine the best coarse of action.
Use established practice standards to guide decisions and actions.
Always put the client’s right an welfare first.
Develop effective interpersonal relationships with clients and families.
Accurately and thoroughly document all assessment data, treatments,
interventions and evaluations of the clients response to care.
 ETHICAL ISSUES

• ETHICS: is a branch of philosophy that deals

with values of human conduct to the rightness
or wrongness of actions and to the goodness
and badness of the motives and ends of such
actions. The ethical theories are sets of
principles used to decide what is morally right
or wrong.
…cont…ETHICAL ISSUES
GUIDELINES FOR SECLUSION
AND RESTRAINT
SECLUSION
 RATIONALE

• To prevent injury or death to aggressive patient,

other patient, and staff and to prevent the
distraction of property and the environment.
Knowledge of the patient’s history of violence and
awareness of behavior that indicate risk of violence
are critical factor in the prevention of violence.
 NURSING ASSESSMENT

• Patient demonstrates behavior that are aggressive and / or potentially destructive

to self or others. Behaviors may be subtle or obvious or nonverbal.
• EXAMPLE of VERBAL BEHAVIOR
Shouting obscenities
Threat to self or others
 EXAMPLE of NONVERBAL BEHAVIOR
Sudden changes in behavior, e.g., patient who has been reasonably calm suddenly
become agitated or a patient who has been reasonably active suddenly becomes
quite or withdrawn; psychomotor agitation that increases in intensity; clenched
jaw, pacing back and forth in an agitated manner, bumping carelessly into walls,
furniture, or person in the environment.
PLAN OF ACTION AND RATIONALE

• Immediately inform key staff of patient’s aggressive

behavior to prevent harm or injury to patient, other
patients and staff (never leave an aggressive patient
unattended or attempt to control a potentially
dangerous patient without qualified help.
• Plan to approach the patent on a continuum, using
the least restrictive to most restrictive measures as
a model for intervention.
MODEL FOR INTERVENTION

• Verbalize methods to help patient maintain

control and dignity.
• Medicate patient as necessary
• Seclude
• restraint
INTERVENTION AND RATIONALE

• Intervene as soon as t he patient begins to

act in a aggressive manner, and attempt to
identify sources leading to aggressive
behavior, if possible, to resolve volatile
issues and prevent escalation of behavior.
 VERBAL INTERACTION

• Approach patient in a calm, direct, non-challenging manner,

to assure patient that staff is in control in order to increase
patient’s control and trust in staff.
• Offer patient the opportunity to control self, indicating that if
this is not possible, staff will assist in helping to control
patient until he or she can regain control, to ensure security
and safety of patient and others in the environment.
 Cont…. VERBAL INTERACTION

• Inform patient that his or her concern will be addressed as soon as

patient regain control, to reinforce staff’s expectations t hat patient
will regain control and to promote trust.
• If patient calm down at any time during the verbal interaction,
quietly accompany patient to an areas of decreased stimulation, to
decrease anxiety and exert least restrictive measures whenever
possible.
• If patient’s behavior fails to response to verbal intervention,
prescribed medication may be required to continue to use least
restrictive measures.
 INTERVENTION AND RATIONALE IN THE USE OF
SECLUSION POLICY
• On determining the necessity for the use of seclusion room obtain the physician’s
written order or, in an emergency, obtain the written order or, in an emergency,
obtain the written order from the charge nurse and secure the order form the
attending physician within a reasonable period of time. (all orders for the use of a
seclusion room must comply with individual state law)
• The charge nurse documents the justification for the use of the seclusion room,
which include the following:
Events leading up to the need for seclusion
Other interventions used prior to seclusion.
Length of time for use of seclusion room.
Clinical justification for length of seclusion time.
 PROCEDURE OF SECLUSION AND RESTRAINT
• Explain procedure and purpose of seclusion to patient before being placed in the
seclusion room, to inform and support the patient and reduce anxiety.
• Escort the patient into the seclusion room in a calm, direct manner that does not
cause discomfort, harm, or pain, to ensure the patient’s safety and preserve his or
her dignity. (the charge nurse should be present to observe the procedure).
• Check the patient every 15 minutes with a qualified staff person, to ensure safety
and provide support, reassurance, and opportunities for the patient to vent
feelings.
• Supervise the patient’s nutrition, hygiene, grooming, and elimination needs, to
ensure the patient’s comfort and safety. (Bathroom privileges should be at least
every 2 hours).
 Cont… PROCEDURE OF SECLUSION AND
RESTRAINT
• Regulate number of people who enter the seclusion room, to
reduce stimulation and provide consistent, therapeutic
relationships. (only the physician, nurses, and primary therapist
should have access to the seclusion only).
• Ensure safety exit of patient in case of emergency (fire,
disaster) to ensure patient’s safety. ( the seclusion room door
should open automatically when the alarm is sounded).
 Provide continual Documentation
• NURSE DOCUMENTATION INCLUDES THE FOLLOWING…
 factors, events and patient behaviors prior seclusion.
Other interventions used prior to seclusion.
Time the physician and/ or charge nurse was notified and time the patient was seen
for purpose of seclusion room.
Name of nurse who accompanied patient to seclusion room.
Name the staff person who supervised and checked patient.
Patient’s response to seclusion room.
Time that patient is removed form seclusion room.
• Notify physician, medical director, and all appropriate administrative personnel, to
inform key people of the patient’s status.
 APPLICATION OF SECLUSION

• FOR ADULT CLIENTS.

Use of restraint and seclusion requires a face-to-face
evaluation by a licensed independent practitioner within
1 hour of restraint or seclusion and every 8 hours
thereafter, a physicians order every 4 hours documented
assessment by the nurse every 1 to 2 hours, and close
supervision of the client.
 … cont… APPLICATION OF SECLUSION
• FOR CHILDREN.
The physicians order must be renewed every
2 hours, with a face-to-face evaluation every
4 hours.
• Staff must monitor a client in restraints continuously on a one-to-
one basis for the duration of the restraint period.
• A client in seclusion in monitored one-to-one for the first hour and
then may be monitored by audio and video equipment.
 … cont… APPLICATION OF SECLUSION

• The nurse assess the client for any injury and provides treatment as
needed, monitors and documents t he client’s skin condition, blood
circulation in hands and feet (for the client in restraints), emotional
being, readiness to discontinue seclusion and restraint.
• Also, observes the client closely for side effects of medications, which
may be given in large doses in emergencies.
• The nurse or designated care provider also implements and documents
offers of food, fluids, and opportunities to use the bathroom per facility
policies and procedures. ASAP, staff members must inform the client of
the behavioral criteria that will be used to determine whether to
decrease or to end the use of restraints or seclusion.
 … cont… APPLICATION OF SECLUSION
• CRITERIA MAY INCLUDE:
Client’s ability to verbalize feelings and concerns rationally, to make no verbal
threats, to have decreased muscle tension, and to demonstrate self-control.

• IF A CLIENT REMAINS IN RESTRAINTS FOR 1 TO 2 HOURS, TWO STAFF

MEMBERS CAN FREE 1 LIMB AT A TIME FOR MOVEMENT AND EXERCISE.
frequent contact by the nurse promotes ongoing assessment of the
client’s well-being and self-control. It also provides an opportunity for the
nurse to reassure the client that restraint is a restorative, not punitive,
procedure. Following release from seclusion or restraint, a debriefing
session is required within 24 hours. Also support the family of the client.
 RESTRAINT
- Direct application of physical force to a person without his or her permission to
restrict his her freedom of movement. The Physical force is either HUMAN RESTRAINT
or MECHANICAL RESTRAINT.

- HUMAN RESTRAINT- occurs when staff members physically control the client and
move him or her to a seclusion room.
- MECHANICAL RESTRAINT-are devices, usually ankle and wrist restraints, fastened to
the bed frame to curtail the client’s physical aggression, such as hitting, kicking and
hair pulling.
Mechanical restraints
Human restraint
 TYPES OF RESTRAINT

1. BELT RESTRAINT
 …CONT…TYPES OF RESTRAINT

2. JACKET RESTRAINT
 …CONT…TYPES OF RESTRAINT

• 3. MITT RESTRAINT
 …CONT…TYPES OF RESTRAINT
4. WRIST OR ANKLE RESTRAINT.
 …CONT…TYPES OF RESTRAINT

5. ELBOW RESTRAINT
 RESTRAINT

• RATIONALE: to provide temporary external

controls for patients who cannot provide
their own internal controls on the unit or in
the seclusion room and whose behavior
may result in injury to the patient or
others.
 RESTRAINT POLICY

• Obtain a physician’s written order or, in an

emergency situation, a registered nurse’s after he
or she has observed and assessed patient, to
provide adecuate justification for use of (leather)
restraints and comply with state laws.
 DOCUMENTATION (Mandatory for Restraint
Order)
Events leading up to restraint.
Rational for use of restraint
Length of time patient is to be restrained.
Justification for length of time.
Notification of attending physician and others in according
with states mental health laws, to ensure adequate
documentation of restraint order, provide ongoing
communication, and comply with laws that protect patient’s
rights.
 PROCEDURE (Restraints) (Supervised by qualified
Charge Nurse)
Provide an adequate number of trained staff nurse, to prevent injury to patients and
staff.
Use a minimum amount of restraints, to ensure patient’s safety with least amount of
control.
Explain to patient briefly and simply the reason for use of restraints , to assure
patient that staff is in control.
Set up restraints in bed in seclusion room ( Should be done in advance, although
restraint are never left unattended), to ensure organized application of restraint and
promote safety.
Apply (leather) restraint to all four extremities in a manner that will control patient
but will not cause undue physical or emotional discomfort, to control patient,
prevent injury to patient or staff, and maintain patients' dignity as much as possible.
 Cont…PROCEDURE (Restraints) (Supervised by
qualified Charge Nurse)
• Inform patient as simply as possible, in a matter-of-fact way, what is happening and
why, to facilitate patient’s understanding without offering own biases and
interpretation.
 “you are being restrained so you will have time to control your behavior”
“ we’re concerned that your behavior will harm you or others”
 Refrain from unnecessary authoritative or condescending remarks, to prevent undue
anger or shame. (example of non-therapeutic statements):
“we warned you this would happen”
“this is for your own good”
• Check the patient every 15 minutes with a qualified staff person, to prevent isolation
and assure patient of staff concerns.
•
Cont…PROCEDURE (Restraints) (Supervised by
qualified Charge Nurse)
• Examples:
Allow patient to perform active range-of-motion exercise (if safe to remove
restraints)
Provide passive range-of-motion exercises on each extremity every 2 hours (if
unsafe to remove restraints).
 Offer bathroom privileges every 2 hours, to provide for basic needs.
 Check circulation and skin conditions as necessary, to maintain circulatory function
and prevent skin breakdown.
 Offer fluids and nutrition, to maintain dietary and hydration needs.
DOCUMENT THE FOLLOWING BY REGISTERED NURSE
Events leading up to need for restraints.
Least restrictive measures attempted (including medication) prior to restraints.
Response of patient to least restrictive measures.
Statement the registered nurse was present when patient was placed in restraints.
Specific individuals who ordered use of restraint.
Whether or not the patient was examined prior to being placed in restraints.
Exact time restraints were applied.
Exact time patient was removed form restraints for relief periods.
Summary of patient’s response to restraints and relief periods.
Time patient was removed form restraints and patient’s behavior at that time.
 POST RESTRAINT PROCEDURE
• Notify those individuals required by law, to comply with state laws.
• Notify attending physician to inform physician and plan subsequent care.
• Release patient from restraints immediately in case of fire or other disaster, to
ensure patient’s safety.
• Approach patient and provide opportunity to talk ( Registered Nurse). Patients who
have just been released form restraints may need to discuss their thoughts and
feelings.
• Discuss procedure and feeling about procedure with staff members involved in
restraint of the patient, clarify own and other’s perceptions feelings among trusted
colleagues.